Migraine Headaches: New Guidelines Focus on Prevention

From prescription pills to poisonous plants, plenty of treatments can help prevent migraines, according to new guidelines from the American Academy of Neurology.

The updated guidelines could help some of the country's 30 million "migraineurs" reduce the frequency and severity of their headaches.

"About 38 percent of people who suffer from migraines could benefit from preventive treatments, but only less than a third of these people currently use them," said Dr. Stephen Silberstein, director of the Jefferson Headache Center at Thomas Jefferson University in Philadelphia and lead author of the guidelines released today.

Migraines are a type of headache often accompanied by nausea, sensitivity to sound and "aura," or visual symptoms. Acute treatments can ease the ache once it's started. But people with frequent migraines are advised to try daily therapies to prevent the pain and dampen the dread of when and where the next headache will hit.

"People who have relatively mild migraines that come infrequently and respond well to acute treatments, those people don't need preventive therapy," said Dr. Richard Lipton, director of the Montefiore Headache Center in New York City. "But if you're losing more than [10 percent of your life] to your migraines, it's probably worth taking medication on a daily basis."

Silberstein and colleagues reviewed the slew of studies on migraine prevention to tease out treatments that were proved to work from ones that were probably ineffective. Among those with "established efficacy" were anti-seizure drugs such as topiramate, blood pressure-lowering drugs called beta-blockers, and inflammation-blocking extracts from the toxic butterbur plant.

"There are many, many different treatments and they have many effects on brain physiology," said Dr. Joel Saper, director of the Michigan Headache and Neurological Institute in Ann Arbor. "Some people need one kind of an effect to feel better; some need another. Some need multiple treatments at the same time."

Preventive treatments that are considered "probably effective" include antidepressants such as amitriptyline, over-the-counter painkillers such as ibuprofen, and natural supplements such as riboflavin.

"Some people say, 'I really don't want be on a medication," said Dr. Audrey Halpern, a neurologist at NYU Langone's Joan H. Tisch Center for Women's Health in New York City. "It may be appropriate for them to start with a natural supplement or other complementary therapy to get them going."

But Halpern stressed that "natural" doesn't necessarily mean "safe."

"Some supplements may interact with other medications," she said. "It's really important for people to talk to their doctors before starting any therapy."

One natural supplement, butterbur extract, has been used to treat migraine for more than 500 years. But only recently was its migraine-fighting potential proved in a clinical trial.

"The great thing about butterbur is it has a very favorable side effect profile," said Lipton, cautioning that supplements were not regulated by the U.S. Food and Drug Administration. "One of the issues with natural compounds is they're very complex. It's a very complex biochemical soup."

Preventing Migraine Pain

Some of the treatments listed in the guidelines are FDA-approved to treat migraines. But many are approved for other conditions and used off-label in migraineurs.

"The fascinating thing about migraine prevention is almost all the therapies we have were developed for another purpose and discovered to work in migraine prevention by chance alone," said Lipton, describing how drugs designed for epilepsy and hypertension were found to work haphazardly in headache sufferers. "But I think we're moving into an era where we can develop designer drugs specifically for migraine."

The new guidelines are similar to those from 2000 with a few changes: Topiramate is now considered effective in migraine prevention; and gabapentin and verapamil were downgraded from "probably effective" to a category of treatments with "inadequate" evidence to support or refute its use. But experts emphasize the guidelines are not the be-all, end-all.

"They're useful as a starting point," said Saper, adding that difficult cases often required drugs not listed in general guidelines. "Many people respond well to drugs that don't help most other people, and those drugs don't get listed because there's not enough evidence of a generalized benefit."